Nursing Care for Pressure Ulcers

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Questions and Answers

What is the primary risk factor for the development of Ms. Pimm's stage 3 pressure injury?

Pressure from the knee brace (correct)

Prolonged immobility

Poor dietary habits

Recent surgery

Which dietary concern should be monitored closely for Ms. Pimm?

Inadequate calories

Low calcium levels

High sodium intake (correct)

High fiber intake

What behavior might impact Ms. Pimm's recovery negatively?

Seeking emotional support

Eating a balanced diet

Regular physical exercise

Smoking tobacco (correct)

What psychosocial factor may affect Ms. Pimm's emotional well-being during recovery?

Desire for independence Signup and view all the answers

What should be the priority focus for the home health agency nurse during Ms. Pimm's visits?

Evaluating the effectiveness of pain management Signup and view all the answers

What common misconception about pressure injuries might Ms. Pimm hold?

They only occur in immobile patients Signup and view all the answers

Which statement best reflects Ms. Pimm's current health risk profile?

She is at risk due to a combination of dietary issues, smoking, and stress. Signup and view all the answers

Given Ms. Pimm's current living situation, what is an important consideration for the nurse?

Her willingness to accept help from others. Signup and view all the answers

What is a primary benefit of maintaining or improving patient activity levels?

Reduces potential for immobility Signup and view all the answers

Which dietary components are noted to be associated with the development of pressure injuries?

Kilocalories, protein, and iron Signup and view all the answers

What should the nurse do if a patient's dietary intake remains inadequate after interventions?

Consult with a dietitian Signup and view all the answers

How can compromised dignity affect a patient who is immobile?

It can lead to situational low self-esteem Signup and view all the answers

What is an important initial action that nurses should take regarding patient dignity?

Assess for indicators of abuse or neglect Signup and view all the answers

What is the recommended frequency for evaluating a treatment plan for patients who are immobile?

As often as daily Signup and view all the answers

Which strategy should nurses not use to help maintain a patient's dignity?

Disregarding patient concerns Signup and view all the answers

What approach should nurses take if they identify barriers to a patient's adequate nutrition?

Work with the patient to find solutions Signup and view all the answers

What is a possible consequence of poorly hydrated skin?

Fissuring and cracking of the stratum corneum Signup and view all the answers

Which practice should be avoided to prevent deep tissue trauma?

Massaging over bony prominences Signup and view all the answers

What should be done to minimize skin exposure to moisture?

Change underpads frequently Signup and view all the answers

What type of injury occurs when the skin remains still while the underlying tissue shifts?

Shear injury Signup and view all the answers

What is the recommended repositioning frequency for an at-risk patient?

Every two hours Signup and view all the answers

Which of the following devices should not be used for pressure relief?

Doughnut-type device Signup and view all the answers

What is a key factor in maintaining skin integrity and promoting wound healing?

Adequate nutrition and hydration Signup and view all the answers

What change in patient condition should prompt immediate contact with a healthcare provider?

Early signs of pressure injury Signup and view all the answers

What should be avoided to reduce friction injuries?

Skin contact with coarse surfaces Signup and view all the answers

Which positioning strategy increases the risk of pressure injury?

Directly lying on trochanters Signup and view all the answers

What is a suggested practice for patients who are chair-bound?

Reposition every hour Signup and view all the answers

Which professional is commonly involved in care for patients at risk for pressure injuries?

Physical therapist Signup and view all the answers

What main aspect should be included in patient education regarding pressure injuries?

Skin hygiene practices Signup and view all the answers

What is the role of assistive devices in patient care?

Help reduce shear and friction injuries Signup and view all the answers

What characterizes a stage 3 pressure ulcer?

Full-thickness skin loss with damage to subcutaneous tissue without necrotic tissue. Signup and view all the answers

Which of the following interventions should be included when teaching Ms. Pimm about wound care?

Monitor for signs of infection. Signup and view all the answers

What is an appropriate over-the-counter medication for Ms. Pimm's postoperative and ulcer pain?

Ibuprofen Signup and view all the answers

What should be a primary goal for Ms. Pimm in her care plan?

To decrease her daily consumption of cigarettes. Signup and view all the answers

Which of the following is NOT a potential diagnosis for Ms. Pimm's condition?

Infection related to viral load. Signup and view all the answers

What is the purpose of a hydrocolloid dressing?

To maintain a moist environment for wound healing. Signup and view all the answers

How often should Ms. Pimm's hydrocolloid dressing be changed after one month of treatment?

Every fifth day. Signup and view all the answers

What important aspect should be included in Ms. Pimm’s diet to promote wound healing?

Adequate nutrients that support healing. Signup and view all the answers

Which of the following factors is NOT listed as contributing to Ms. Pimm's impaired skin integrity?

Excessive physical activity. Signup and view all the answers

What should be performed to minimize the risk of pressure injuries?

Conduct systematic skin inspection daily. Signup and view all the answers

What is an advised method for cleaning Ms. Pimm's skin?

Use mild cleansing agents and warm water. Signup and view all the answers

When should Ms. Pimm effectively use the soft elastic sleeve-type brace?

When walking or sleeping if more support is needed. Signup and view all the answers

How is the nurse's frequency of visits to Ms. Pimm adjusted during her recovery?

From daily to three times a week. Signup and view all the answers

What should be monitored to identify the development of infection in Ms. Pimm's wound?

Changes in drainage color or increased warmth. Signup and view all the answers

Study Notes

Patient Case Study

Agnes Pimm, 74 years old, underwent knee replacement surgery and developed a stage 3 pressure ulcer on her leg due to supportive knee brace irritation.
Ms. Pimm is independent, lives at home, and has a history of hypertension, smoking, and grief after her husband's death.
She has a low protein and high sodium diet, struggles with appetite, and has difficulty accessing fresh foods.
The wound is clean, without necrotic tissue, and exhibits no signs of inflammation or infection.
Nurse Jessi Fletcher has been assigned to Ms. Pimm's care and assesses the patient's skin integrity.
Nursing diagnoses include: Potential for infection related to pressure injury, Impaired skin integrity, Acute pain, Undernutrition, and Grieving.
Ms. Pimm's care plan focuses on wound healing, infection prevention, nutrition, pain management, and smoking cessation.
The care plan implementation includes teaching Ms. Pimm about medication administration, wound care, and infection prevention, as well as demonstrating the proper method for cleaning and dressing the pressure injury.
Ms. Pimm is referred to a dietitian to create a wound healing meal plan suitable for her hypertension.
Ms. Pimm struggles with her diet but shows an understanding of healthy eating and makes an effort to follow the dietitian's meal plan.
Ms. Pimm struggles with smoking cessation despite trying various methods. She is referred to community resources for smoking cessation support.
The nurse provides home health visits and the wound improves to stage 2 after a month of treatment.
Over time, Ms. Pimm takes over wound care responsibilities and the frequency of home visits is reduced to three times a week.

Interventions for Patients at Risk for Impaired Skin Integrity

Regular skin inspection: At least once a day, paying attention to bony prominences.
Skin cleansing: Clean the skin when soiled and at routine intervals, using mild cleansing agents and gentle techniques.
Minimize environmental factors: Avoid hot water, low humidity, and exposure to cold. Use moisturizers to treat dry skin.
Avoid massage: Avoid massaging over bony prominences to minimize deep tissue trauma.
Moisture management: Minimize skin exposure to moisture caused by incontinence, perspiration, or wound drainage. Use absorbent underpads and briefs, and change them frequently. Avoid placing plastic directly against the skin.
Positioning and turning: Use proper positioning, transferring, and turning techniques to reduce friction and shear injuries.
Pressure relief: Reposition the at-risk patient a minimum of every 2 hours using a written schedule.
Positioning devices: Use pillows or foam wedges to protect bony prominences.
Head of bed elevation: Maintain the head of the bed at the lowest degree of elevation consistent with the patient's medical condition.
Assistive devices: Use assistive devices, such as a trapeze or drawsheet, to move patients who can't assist during transfers and position changes.
Pressure-reducing devices: Use pressure-reducing devices for chair-bound patients.
Written plan: Create a written plan for positioning, movement, and the use of positioning devices.
Collaboration: Collaborate with physical therapists, primary caregivers, and other healthcare professionals.
Patient and caregiver teaching: Educate patients and caregivers about pressure injuries, risk factors, skin care, and prevention strategies.
Referral: Refer patients to home health agencies or community health departments for support.

Prevent Infection of Pressure Injuries

Maintain skin hygiene: Keep the skin clean, dry, and moisturized.
Maintain appropriate nutrition and hydration: Ensure adequate protein and carbohydrate intake and hydration status.
Early recognition: Recognize early stages of pressure injuries for immediate intervention.
Contact healthcare provider: Contact the healthcare provider at the earliest appearance of a pressure injury or change in skin integrity.
Maintain activity levels: Encourage patients to maintain or improve current activity levels.

Prevent Nutritional Imbalance

Assess dietary intake: Assess factors related to dietary intake.
Nutritional supplements: Offer nutritional supplements.
Mealtime support: Support patients during mealtimes.
Consult dietitian: Consult with a dietitian if barriers to adequate nutrition exist.

Prevent Compromised Dignity and Situational Low Self-Esteem

Assess for abuse and neglect: Assess for indicators of abuse or neglect during healthcare interactions.
Build a trusting relationship: Develop a trusting, caring relationship with the patient.
Educate patients and family members: Provide essential patient and family teaching to reduce the risk of pressure injury development and promote patient dignity.
Assist with supportive devices: Assist patients and family members with obtaining supportive devices to help maintain appropriate positioning.

Evaluation

Monitor skin integrity, comfort, and pain level regularly.
Evaluate and modify the treatment plan as needed, potentially daily.
Monitor dietary intake and consult with a nutritionist or dietitian if needed.
Inform mobile patients when to call the office if they discover a potential pressure injury or change in skin integrity.

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Description

This quiz focuses on the case study of Agnes Pimm, a 74-year-old patient with a stage 3 pressure ulcer following knee replacement surgery. It covers nursing assessments, diagnoses, care plans, and patient education to promote wound healing and overall health management. Test your understanding of effective nursing care strategies for elderly patients with complex needs.